MEDICARE: MR. FREDERICK STEVEN JESTRAB RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P1300X	Psychiatric Pharmacist	PH00010322	WA

General Provider Information

NPI Number	:	1225035728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FREDERICK STEVEN JESTRAB RPH

Provider Business Mailing Address
First Line	:	3119 OLYMPIC BLVD W
Second Line	:
City	:	UNIVERSITY PLACE
State	:	WA
Zip	:	98466-1605
Country	:	US
Telephone Number	:	253-566-6621
Fax Number	:	253-756-2707

Provider Business Practice Location Address
First Line	:	9601 STEILACOOM BLVD SW
Second Line	:	WESTERN STATE HOSPITAL- MAIL STOP 13-100
City	:	TACOMA
State	:	WA
Zip	:	98498-7213
Country	:	US
Telephone Number	:	253-756-2521
Fax Number	:	253-756-2707

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	07/08/2007

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